Jeffrey D. Sadow is an associate professor of political science at Louisiana State University Shreveport. If you're an elected official, political operative or anyone else upset at his views, don't go bothering LSUS or LSU System officials about that because these are his own views solely.
This publishes Sunday through Thursday with the exception of 7 holidays. Also check out his Louisiana Legislature Log especially during legislative sessions (in "Louisiana Politics Blog Roll" below).

The Legislature this year passed a $4 million in line items to mandate new
ongoing spending for 200 additional slots for this. Waiver programs let states
use federal Medicaid dollars to give services to the developmentally disabled
or elderly who would not otherwise qualify for the program on the basis of
income or assets, as long as the average cost per client does not exceed what
the state would spend on paying for them to live in nursing homes.

With a waiting list of approaching 11,000 for NOW, at least a small
dent could have been made in that, where some on the list with severe
disabilities have waited for eight or more years. But citing legislative
directives that produced a health care budget $40 million in the red ordering
the executive to make cuts, Gov. Bobby
Jindalvetoed
those line items.

The resources involved aren’t trivial. In Fiscal Year 2012,
$457 million was spent on 8,425 NOW recipients while another $206 million for 8,241
clients was spent on other waiver programs. NOW differs from the others because
it provides skilled nursing services and as much as around-the-clock care,
which the others separately do not. However, not all hours given have to be
skilled nursing, and many on the waiting list already receive a high level of
services from the other waivers at an intense level. Nor at the time of
offering do all applicants have need of services at the NOW level; for this and
other reasons, fewer than half of NOW offers are accepted.

Several reasons explain the list’s length. First, Louisiana’s previous
strategy, before court decisions forced it to shift emphasis to home- and
community-based services, was to warehouse the elderly and disabled into
nursing homes, so the abrupt transition meant a lot of catching-up (as well as reducing
wasteful spending to nursing homes that seems set to continue for some
time, dollars which otherwise could have gone to waiver services). Second, in
that rush Louisiana overcompensated in terms of people made eligible for NOW
and in the level of services provided across all waiver programs, with the
rebalancing beginning only after Jindal took office. Third, with the creation
of the several programs beginning with NOW in 2003 (each is petitioned to the
federal government, which then must approve them and any changes made after),
it was difficult to stitch them together in a way that provided an efficient continuity
of care.

For an example of this, a child under 18 qualifies either for NOW or a
Children’s Choice Waiver depending on the need for skilled nursing. But what if
prior to the child’s 18th birthday a change in health conditions
causes a need for skilled nursing where one previous did not exist? Under
current regulations, NOW is first-come-first-served, so a coverage gap would exist.
This then creates an incentive to get the child placed initially on the NOW
waiting list in anticipation, whether the need ever manifests, of such needs,
while in the interim the child uses CCW.

Going to a need basis totally in determining NOW recipients largely solves for
this, and that’s what happened last week as advocates called upon legislators
to back an override session and then to override the NOW item veto when the
Department of Health and Hospitals said that standard could start within the
year. This would deliver NOW services to more people more quickly, although some
adjustment should be made to allow long-time waiters of lower need not to have
to wait several more years to receive services. This would make the awarding
process more responsive and create incentives to match program to genuine need.

But more can be done. Revamping of rules can create more seamless ability
to transit from one kind of waiver to another as ages (some differ between
children and adults) and needs change, to eliminate incentive to clog the NOW
list, and to make sure nobody falls through the cracks (such as when turning 18
and becoming ineligible for one program only to be faced with a waiting list
for another similar one for adults for which then they would have to apply).

Rules revision also can allocate personnel resources more efficiently;
currently, the one-size-fits-all staffing model for providers does not induce
incentives for matching staff capabilities to client needs. For example, reimbursement
levels by the state to providers could depend upon demonstrated competencies of
employees, which then could pay more skilled workers higher wages for households
whose clients have greater demands; this is something DHH already is reviewing.

Technology also can assist. To ensure that contracted providers are
meeting service commitments, using verification systems that indicate employee
arrival and departure can be mandated for all providers, not just for skilled
nurses. Personnel even may not be necessary for low needs individuals, where electronic
monitoring can suffice.

Finally, although vilified
by some when introduced a few years ago, the resource allocation model
approach that identifies needs that then on a rational basis can be fit to
resources required, perhaps in concert with the move to need-based allocation
of NOW, can be extended in its discriminatory power to make sure that the
appropriate amount and level of services are being provided. This will stretch
dollars and get more clients services and more quickly.

In other words, it’s not just a matter of money needed to increase
service levels. While advocates do well to call attention to a gap in service,
policy changes can accomplish closing at least some of this gap. And it’s to
DHH’s credit that increasingly it’s open to making, if not implementing, these
changes.

About Me

Subscribe To

Comment publishing requirements

You must be a registered user with an OpenID-compliant service to leave comments, which will be moderated. Any comments that do not address issues in the post for which they are intended will not be posted; neither will those that utterly lack intellectual coherence.